Basic Information
| Provider Information | |||||||||
| NPI: | 1174976856 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOMINIC | ||||||||
| FirstName: | LYDIA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 930 MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275142656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199333301 | ||||||||
| FaxNumber: | 9199333375 | ||||||||
| Practice Location | |||||||||
| Address1: | 930 MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275142656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199333301 | ||||||||
| FaxNumber: | 9199333375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2016 | ||||||||
| LastUpdateDate: | 07/19/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 231729 | NC | N | Nursing Service Providers | Licensed Practical Nurse | 367A00000X | 607 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
No ID Information.